Exam (elaborations)
Chapter 5. Documentation
- Course
- Fundamentals of Nursing Care
- Institution
- Allegany College Of Maryland Somerset Campus
Chapter 5. Documentation
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Chapter 5. DocumentationMultiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse is educating a student nurse about documentation. The nurse recognizes that additional
teaching is required when the student nurse states,
A. “Documentation serves as a temporary part of the medical record.”
B. “Documentation is one of the most important tasks that I’ll perform in nursing.”
C. “Documentation is the act of charting pertinent information related to a patient.”
D. “Documentation is evidence of what transpired during an event requiring medical
care.”
2. When documenting in a patient’s chart, the nurse recognizes that
A. Documentation serves as a temporary part of the medical record.
B. Documentation is one of the least important tasks performed in nursing.
C. Documentation is the act of charting only abnormal information related to a patient.
D. Documentation is evidence of what transpired during an event requiring medical
care.
3. The nurse is educating a student nurse about the purpose of written documentation. The nurse
recognizes that additional teaching is warranted when the student nurse states,
A. “The purpose of written documentation is to communicate pertinent data to the
health care team.”
B. “The purpose of written documentation is to serve as a record of accountability for
accreditation.”
C. “The purpose of written documentation is to serve as a legal record for the health
care provider only.”
D. “The purpose of written documentation is to serve as a record of accountability for
quality assurance.”
4. The nurse educates a nursing student about effective patient care. The nurse recognizes that
additional instruction is needed when the nursing student states,
A. “For patient care to be effective, it must be delivered periodically.”
B. “For patient care to be effective, it must be delivered continuously.”
C. “For patient care to be effective, it must be evaluated continuously.”
D. “For patient care to be effective, it must be delivered
systematically.”
5. A hospitalized patient tells the nurse that he wishes to take the original chart copy of his medical
record home. The nurse’s best response is:
A. “You may not have it because it belongs to your physician.”
B. “It is your medical record and you are allowed to take it home.”
C. “It is against hospital policy for you to look at your medical record.”
D. “You are allowed to have a copy of your medical record to take home.”
6. A nurse is caring for a patient who just fell from the bed onto the floor. The nurse should write a(n)
, A. Emergency record.
B. Incident report.
C. Progress report.
D. Grievance report.
7. The nurse is aware that the best method to ensure documentation accuracy is to consistently chart
A. At the completion of each shift.
B. Within 4 hours of providing care.
C. Immediately after care is provided.
D. Immediately prior to providing care.
8. The nurse teaches a student nurse about what type of occurrence requires completion of an incident
report. The nurse recognizes that additional instruction is warranted when the student nurse states,
A. “If my patient falls out of a chair, I will complete an incident report.”
B. “If I give the wrong medication to my patient, I will complete an incident report.”
C. “If a visitor is injured while seeing my patient, I will complete an incident report.”
D. “If my patient refuses to ambulate with physical therapy, I will complete an
incident report.”
9. A nurse discovers a patient lying on the floor. When completing an incident report, the nurse
should write:
A. “Patient fell out of bed onto the floor.”
B. “Heard patient fall from the bed to the floor.”
C. “Patient accidentally fell out of bed onto the floor.”
D. “Found patient lying face down on the floor beside the bed.”
10. A nursing instructor is educating a student nurse about military time. The time is 6:00 PM The
student nurse demonstrates understanding by documenting the time as
A. 1500.
B. 1600.
C. 1700.
D. 1800.
11. A student nurse is caring for a patient who is on a clear liquid diet. The best example of nursing
documentation related to this patient is:
A. “Average intake of clear liquid diet noted.”
B. “Patient tolerates the clear liquid diet well.”
C. “Patient swallowing clear liquids normally.”
D. “No complaints of nausea while on clear liquid diet.”
12. A nursing instructor is educating a class of student nurses about patient documentation. The best
example of patient documentation is:
A. States “He vomited everything he ate and drank yesterday.”
B. States “He is in excruciating pain. The pain is unrelieved by analgesics.”
C. States “The pain is getting worse. I don’t know if I can stand it or not.”
D. States “His pain is getting worse and he doesn’t know if he can stand it or not.”
, 13. When documenting in a patient’s chart, the nurse realizes that it is the wrong patient’s chart. The
nurse should
A. Write over the incorrect letters.
B. Use correction fluid to blank-out the mistaken entry.
C. Use correction tape to blank-out the mistaken entry.
D. Write “mistaken entry” and his or her initials just above incorrect
entry.
14. The nursing instructor observes a student nurse documenting in the wrong patient’s chart. The
nursing instructor would intervene when observing the student nurse
A. Writing initials just above the incorrect
entry.
B. Using a marker to blacken the incorrect entry.
C. Writing “mistaken entry” just above incorrect
entry.
D. Marking a single horizontal line through the incorrect entry
15. The nursing instructor educates a class of nursing students about SOAPIER charting. The nursing
instructor teaches that the acronym SOAPIER stands for
A. Symptoms, Objective, Assessment data, Plan, Intervention, Evaluation, Revision.
B. Subjective data, Objective data, Assessment data, Plan, Intervention,
Evaluation,
Results.
C. Subjective data, Objective data, Assessment data, Plan, Intervention,
Evaluation,
Revision.
D. Subjective data, Objective data, Assessment data, Problems,
Intervention,
Evaluation, Revision.
16. The nursing instructor educates a class of nursing students about a common type of focus charting
known as DAR. The nursing instructor teaches that the acronym DAR stands for
A. Data, Action, Response.
B. Data, Assessment, Revision.
C. Diagnosis, Action, Response.
D. Data, Assessment, Response.
17. A patient complains of left-sided chest pain radiating to the left shoulder. Using the SOAPIER
method, the nurse should chart this complaint under the initial
A. S.
B. O.
C. A.
D. P.
18. A patient appears anxious. The patient speaks quickly and paces the hospital halls. Using the
SOAPIER method, the nurse should chart this finding under the initial
A. S.
B. O.
C. A.
D. P.
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